HNN320 Leadership and Clinical Governance
Part 1: ESTABLISH THE CONTEXT
During my internship placement, a male patient named Mr. N of age 65 years was admitted into the local emergency department (ED) with the complaints of chest pain and the shortness of breath or dyspnoea. The man had a history of chronic diseases of type 2 diabetes mellitus, hypertension and the chronic obstructive pulmonary disease (COPD). He was admitted into the hospital for the problem of exacerbation of his COPD symptoms along with the atypical chest pain or angina.
At several instances, he was found to be at the fall risk. He even fell once when he was in the acute care ward of the hospital. Further, the patient was shifted onto the rehabilitation unit of the hospital. During my shift, I randomly visited the patient’s room for collecting patient documents and found him lying over the floor and I informed the registered nurse immediately. The RN assessed him and he was diagnosed with the hip fracture and several bruises on the body. On inquiry, the patient gave a statement that “I tried contacting the nurse to help me in the bathroom, but the nurse did not come or made response.” Even the patient’s wife made the allegation that her husband was overmedicated with zolpidem and acetaminophen that increased the fall risk. Moreover, the RN was allocated to care him 24x7 hours due to his critical health and still nurse was missing.
I witnessed that no visible reminders were present to be in their place for alerting the staff members about the fall risk of the patient (like a wristband or a signage). The order stipulated that Mr. N must be given zolpidem at 1700 hours. But, the nurse documented the administration of this drug at 1730 hours. Nonetheless, the hospital’s pharmacy software made assigning of the drug at 2000 hours automatically over the medication sheet as the policy of the hospital made stipulation of zolpidem administration at 2000 hours. The deviation in the administration needs the pharmacy approval. Further, the nurse made a claim that the nurse had checked over the patient about 15 minutes before the fall occurred and she found that the patient was sleeping. This fall case in the rehabilitation unit led to surgical hip repair of the patient. Post additional rehabilitation, he was discharged home. But, he died a month after discharge and a malpractice suit was filed against the hospital for the allegation of improper patient medication management and patient care and failure of the nurse to monitor the physiological status of the patient.
Part 2: APPLY THE CLINICAL RISK MANAGEMENT PROCESS
IDENTIFICATION: How can this risk be identified in practice or how is this risk monitored and recorded?
Fall is a random, not planned descent over the ground regardless of wound or injury to the sufferer. A simple rule of measuring care and quality is: “If you can't measure it, you can't improve it.” Thus, as part of the program for quality improvement, fall prevention strategies and fall rates must be considered, recorded and racked (Barker et al., 2011). When performance is tracked, you will be updated about whether the care is better, is similar or getting worse in response to the actions taken to change the strategies. Furthermore, consistent monitoring helps in knowing where the staff is beginning from and if the improvement gains are stable and sustained or not (Etman et al., 2012).
The falls screening can help in identifying whether a person has a higher or lower falling risk and the risk assessment can notify establishing prevention strategies. Presently, the National Standards need that all the patients hold the documentation of falls risk screening at the time of hospital admission and also on the transfer of the patient between different departments and setting. The examples of the screening tools that are recently being used in Victorian hospitals consist of the Falls Risk Assessment Tool: STRATIFY and FRAT (Barker et al., 2011).
ANALYSIS: How common is this type of risk in practice? What is the significance for patient outcomes?
Australia reports more hospital admissions due to fall-related injuries as compared to the transport related injuries. Moreover, people admitted to the hospital have higher risk of experiencing a fall in hospital. As per the World Health Organization, the fall is termed as "the event which results in a person coming to rest inadvertently on the ground or floor or other lower level". This consists of loss of balance, slips, trips, and even applies towards the situations or events being witnessed and even unwitnessed (Khow & Visvanathan, 2017). The falls is the risk that makes contribution towards elongated length of stay in hospitals, can trigger residential aged care admission and define higher risk of the functional loss or decline. The consequences of falls are associated with death at the worsening level (Haas & Haines, 2014).
Over 700,000 to 1 million of the hospitalized patients experience fall annually. The old patients of the age 60years and above have the increased risk for falls and fatal falls (Khow & Visvanathan, 2017). The falls are the key concern, because the falls significantly result in lacerations, fractures, internal bleeding and several other injuries that can result in the raised healthcare use. The patient fall not just lead to elongated length of stay, but also the healthcare costs. This can also trigger the legal actions or lawsuits causing the settlements of the millions of dollars because of patient injury or death (Haas & Haines, 2014).
The falls are termed as the second leading cause for both the accidental and the unintentional injury based deaths globally. Annually the estimated 646,000 people die due to falls worldwide and out of this about 80% cases occur in the low and middle income nations (AIHW, 2018). The global statistics state that over 37.3 million falls being severe enough to need the medical attention annually (Khow & Visvanathan, 2017). The analysis reveals that the prevention strategies need to focus over training, education, creating safer environments, developing effective policies and prioritizing the fall-related research for reducing the fall risk (Matarese & Ivziku, 2016).
EVALUATION: How can this risk potentially reduced or eliminated in practice? What processes, policies or structures can be put in place to reduce this risk?
With the implementation of the best practices needs attention towards the detail. Certain problems that require to be sorted out at the practice level to potentially eliminate or reduce falls risk are innovative and widely accepted (Huang & Mallet, 2016). The hospital must provide education to all the clinical and nonclinical staff members through innovative learning materials. It is necessary to reach to all nurses with the fall prevention education, certainly the nurses who work during night shift and the weekend staff (Wilkinson et al., 2018). The provision of the fall prevention training is a must for the professional disciplines that are beyond the nursing staff members and the rehabilitation services (for example training for pharmacy, medical residents and physicians) or for the nonclinical staff members (like transport team members and environmental services in hospitals) (Huang & Mallet, 2016).
Furthermore, the hospital must have the policy of clear and frequent communication of fall risk. This is possible through the development of the mechanisms for the emergency department for effectively communicating the patient's risk factors for the falls towards the admitting department in written manner (Waldron, Hill & Barker, 2012). The handoff tools need improvement between the departments and the shifts through the support of advanced technical gadgets (Wilkinson et al., 2018).
The nursing team can be given autonomy and motivational aspect to conduct hourly rounding to know patients’ needs to anticipate patient needs before their occurrence. This way the patients get the assistance in walking to bathroom prior the need of urgency occurs (Waldron et al., 2012). The falls prevention in a necessity in the population of elderly patients; patients with dementia; or patients being confused (Matarese & Ivziku, 2016). They get huge benefits from intentional and frequent rounds. This assures the regular assessment of the patient needs and the changes in their behaviour that can avoid falls and reduce their discomfort. When the pain is controlled, the patient’s possessions become in reach and even their toileting needs met on time (Wilkinson et al., 2018). This way there are lesser chances that they will try to get up with no help or support. All in all the nurses need autonomy and training to implement these effective practices without any delay or a second thought (Huang & Mallet, 2016).
MANAGEMENT: What is the role of the nurse in managing or monitoring for this type of risk?
Fall prevention is a multidisciplinary practice comprising of occupational therapists, physicians, patients, their family members, and specifically nurses. The registered nurses invest in more time with patients (Chu, 2017). Thus, huge responsibility falls on them in direct care. The study indicates that 1/3rd of falls could be prevented. Thus, the nurses have an integral part in the maintenance of safe hospitals. Preventing older patients from falls and injuries define the vital role of nurses (Reuben et al., 2017). The nurse is well placed to drive the organizational change to falls prevention through a team approach for better planning, implementation and evaluation of the falls prevention program. The nurse is also well-positioned to identify the change in fall risk of patient and plays the vital role in having better interaction with all the healthcare team members (Chu, 2017).
Nurse has to follow multiple procedures in falls prevention. The nurse is responsible for completing and documenting the fall risk assessment and screening of the patient and recording the patient-specific fall prevention methods (Brady et al., 2014). The nurse is the professional who reports the falls to the doctor immediately and attains the medical orders from doctor as per the requirement (Waldron et al., 2012). The nurse also supervises and guides the nursing aides. The nurse also plays the role of an educator for the patient and the family members about falls prevention and provides the supplies like bed alarm, walker and cane to avoid patient falls (Reuben et al., 2017).
It has been found that the nursing aides also present a crucial role in falls prevention in patients. They help in timely evaluation of environment of patient for safety during the patient caring duties; implementing the care plan (Brady et al., 2014); and reporting the falls related issues to nurse if the tasks gave not been accomplished; and reporting the alterations in the medical condition of the patient to nurse (Reuben et al., 2017).
Barker, A., Kamar, J., Graco, M., Lawlor, V., & Hill, K. (2011). Adding value to the STRATIFY falls risk assessment in acute hospitals. Journal Of Advanced Nursing, 67(2), 450-457.
Brady, A., McCabe, Catherine, & McCann, Margaret. (2014). Fundamentals of medical-surgical nursing : A systems approach (Fundamentals).
Huang, A., & Mallet, Louise. (2016). Medication-Related Falls in Older People Causative Factors and Management Strategies (1st ed. 2016. ed.).
Khow, K. S., & Visvanathan, R. (2017). Falls in the aging population. Clinics in geriatric medicine, 33(3), 357-368.
Matarese, M., & Ivziku, D. (2016). Falls risk assessment in older patients in hospital. Nursing Standard, 30(48), 53-63.
Reuben, D., Gazarian, P., Alexander, N., Araujo, K., Baker, D., Bean, J., . . . McMahon, S. (2017). The Strategies to Reduce Injuries and Develop Confidence in Elders Intervention: Falls Risk Factor Assessment and Management, Patient Engagement, and Nurse Co‐management. Journal of the American Geriatrics Society, 65(12), 2733-2739.